Beyond Angiography: Intracoronary Imaging Revealing a Left Anterior Descending (LAD) Clot in a 45-Year-Old Male Patient

Figure 1. Chest X-ray with normal cardiac silhouette and no features of congestion or consolidation Black mark is used to ensure complete anonymity

Figure 2. The ECG upon admission to the coronary care unit was largely unremarkable and very similar to the ECG recorded by the ambulance crew ECG: electrocardiogram; AVR: augmented vector right; AVL: augmented vector left; AVR: augmented vector foot

Figure 3. Inpatient invasive diagnostic coronary angiogram The red arrow shows subtotal mid-LAD artery opacification projected as a finger-like filling defect that raised the suspicion of a mid-LAD thrombus or classic plaque rupture LAD: left anterior descending

Figure 4. Different view of the LAD coronary artery Red circle demonstrates subtotal occlusion in the proximal to mid vessel LAD: left anterior descending

Figure 5. OCT image depicting the red thrombus (white arrows) and ruptured plaque at the base of it Analyzing cross-sectionally, the inner (left) purple arrow depicts the IEL layer, the outer (right) purple arrow shows the EEL layer, and the structure in between is the tunica media. Clear EEL visualization helps determine the true vessel boundaries, ensuring appropriate stent diameter selection, adequate lesion coverage, and optimal stent expansion while minimizing the risks of malapposition or vessel injury Red thrombus: rich in red blood cells and fibrin with high backscattering and strong signal attenuation as opposed to a white thrombus, typically rich in fibrin and platelets, homogeneous with low backscattering and little signal attenuation (not represented in the above image) IEL: internal elastic laminate; EEL: external elastic laminate; OCT: optical coherence tomography

Figure 6. Images after insertion of stent Stent apposition in the image on the right; image on the left shows direct correlation with invasive angiogram in the mid-segment (white dash); the bottom image, white pin with orange head, shows the longitudinal section of the lumen with the stent affixed

Figure 7. Another OCT image after stent insertion Dark blue arrows depict a stent with deflected comet-like shadows; red arrows show IVUS lumen devoid of blood; green arrows depict a ballooned lesion now buried within the intima with the DES, and the light blue arrow shows the guide wire DES: drug-eluting stent; OCT: optical coherence tomography; IVUS: intravascular ultrasound

Figure 8. Angiography after stent insertion Post-stent dilatation shows excellent angiographic flow